Research and Reviews in the Fastlane 192

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LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog


Research and Reviews in the Fastlane

Welcome to the 192nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Justin Morgenstern and Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

R&R Hall of Famer - You simply MUST READ this!

Brazil V. Translational simulation: not ‘where?’ but ‘why?’ A functional view of in situ simulation. Advances in Simulation. 2017; 2(1). DOI: 10.1186/s41077-017-0052-3

  • This free-to-access article in Advances in Simulation is a MUST READ if, like me, you share Victoria Brazil’s philosophy that simulation should be a service, not a center, and should translate into improved care of patients and patient outcomes. This article defines the concept of ‘translational simulation’ and is the perfect succinct, academic overview of this exciting area.
  • Recommended by: Chris Nickson

The Best of the Rest

Emergency MedicineR&R Game Changer? Might change your clinical practice
Crowell EL, et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017. PMID: 28662312 

  • Some people rely on CT scan of the orbits to rule in or rule out an open globe. This retrospective chart review, in which CT scans were reviewed independently by a blinded neuroradiologist and ophthalmologist (x2) argues that CT cannot be trusted as the sensitivity was 51% to 77%. The specificity was good at 97% but given this is a diagnosis we don’t want to miss, clinical exam by an ophthalmologist is warranted if you actually think a patient may have a ruptured globe.
  • Recommended by: Lauren Westafer

Critical Care
R&R Hot Stuff - Everyone’s going to be talking about this
Allingstrup MJ, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive care medicine. 2017; 43(11):1637-1647. PMID: 28936712

  • In acute, mechanically ventilated, adult ICU patients, delivering individualised nutrition (based on indirect calorimetry and urinary urea measurements) did not result in improved patient centred outcomes at 6-months, as compared to standard nutrition.
  • Recommended by: Andrew Udy

Emergency Medicine
R&R Mona Lisa -Brilliant writing or explanation” width=
O’Hagan Lucy. Narrating Our Selves: Eric Elder Lecture Presented at the annual conference of the Royal New Zealand College of General Practitioners, July 2016. Journal of Primary Health Care.  1017;9:100-104. DOI: 10.1071/HC15925

  • This in an incredible piece of writing, specifically about general practice, but really just about being a doctor and a human. Must read whatever your specialty.
  • Recommended by: Justin Morgenstern

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this
Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017. PMID: 29125679

  • This randomized, open-label study comparing topical TXA to anterior packing demonstrated a 44% absolute difference in cessation of epistaxis at 10 minutes in the group receiving topical TXA. This NNT of ~2 may be too good to be true but, after application of pressure, TXA should be considered as a next line therapy before the use of packing.
  • Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Jan 18, 2018 @ 1:53 am


Research and Reviews in the Fastlane 192
Justin Morgenstern

Vitamin D improved asthma symptoms and reduced exacerbations

Multiple randomized trials have suggested that vitamin D supplementation might improve asthma control and reduce severity of asthma attacks. A new meta-analysis bolsters that hypothesis, and may encourage more physicians and people with asthma to consider vitamin D supplements for low vitamin D levels. In a study in Lancet Respiratory Medicine, authors analyzed the experience [... read more]

The post Vitamin D improved asthma symptoms and reduced exacerbations appeared first on PulmCCM.

The Final X-Ray In Damage Control Surgery

Damage control surgery for trauma is over 20 years old, yet we continue to find ways to refine it and make it better. Many lives have been saved over the years, but we’ve also discovered new questions. How soon should the patient go back for definitive closure? What is the optimal closure technique? What if it still won’t close?

One other troublesome issue surfaced as well. We discovered that it is entirely possible to leave things behind. Retained foreign bodies are the bane of any surgeon, and many, many systems are in place to avoid them. However, many of these processes are not possible in emergent trauma surgery. Preop instrument counts cannot be done. Handfuls of uncounted sponges may be packed into the wound.

I was only able to find one paper describing how often things are left behind in damage control surgery (see reference below), and it was uncommon in this single center study (3 cases out of about 2500 patients). However, it can be catastrophic, causing sepsis, physical damage to adjacent organs, and the risk of performing an additional operation in a sick trauma patient.

So what can we do to reduce the risk, hopefully to zero? Here are my  recommendations:

  • For busy centers that do frequent laparotomy or thoracotomy for trauma and have packs open and ready, pre-count all instruments and document it
  • Pre-count a set number of laparotomy pads into the packs
  • Use only items that are radiopaque or have a marker embedded in them. This includes surgical towels, too!
  • Implement a damage control closure x-ray policy. When the patient returns to OR and the surgeons are ready to begin the final closure, obtain an x-ray of the entire area that was operated upon. This must be performed and read before the closure is complete so that any identified retained objects can be removed.

Tomorrow, a sample damage control closure x-ray.

Related post:

Reference: Retained foreign bodies after emergent trauma surgery: incidence after 2526 cavitary explorations. Am Surg 73(10):1031-1034, 2007.